Obsessive-Compulsive Disorder

What is OCD?

Obsessive-compulsive disorder (OCD), one of the anxiety disorders, is a
potentially disabling condition that can persist throughout a person's life.
The individual who suffers from OCD becomes trapped in a pattern of repetitive
thoughts and behaviors that are senseless and distressing but extremely
difficult to overcome. OCD occurs in a spectrum from mild to severe, but if
severe and left untreated, can destroy a person's capacity to function at
work, at school, or even in the home.

The following three case histories are typical for those who suffer from
obsessive-compulsive disorder--a disorder that can be effectively treated.

Isobel is intelligent, but she is failing her first period class in
biology because she is either late to class or absent. She gets up at five
o'clock, hoping to get to school on time. The next three hours are spent
taking a long shower followed by changing clothes repeatedly until it "feels
right." She finally packs and repacks her books until they are just right,
opens the front door and prepares to walk down the front steps. She goes
through a ritual of pausing on each step for a particular length of time.
Even though she recognizes her thoughts and behaviors are senseless, she feels
compelled to complete her rituals. Once she has completed these rituals, she
makes a mad dash for school and arrives when first period is almost over.

Meredith's pregnancy was a time of joyous anticipation. If she had
moments of trepidation about taking care of a new baby, these times passed
quickly. She and her husband proudly brought a beautiful, perfect baby boy
home from the hospital. Meredith bathed and fed the baby, comforted him when
he was restless, and became a competent young mother. Then the obsessional
thoughts began; she feared that she might harm her child. Over and over again
she imagined herself stabbing the baby. She busied herself around the house,
tried to think of other things, but the distressing thought persisted. She
became terrified to use the kitchen knives or her sewing scissors. She knew
she did not want to harm her child. Why did she have these distressing, alien
thoughts?

During his last year at college, John became aware that he was spending
more and more time preparing for classes, but he worked hard and graduated in
the top ten percent of his class with a major in accounting. He accepted a
position at a prestigious accounting firm in his hometown and began work with
high hopes for the future. Within weeks, the firm was having second thoughts
about John. Given work that should have taken two or three hours, he was
going over and over the figures, checking and rechecking, spending a week or
more on a task. He knew it was taking too long to get each job done, but he
felt compelled to continue checking. When his probation period was over, the
company let him go.

How Common Is OCD?

For many years, mental health professionals thought of OCD as a rare disease
because only a small minority of their patients had the condition. The
disorder often went unrecognized because many of those afflicted with OCD, in
efforts to keep their repetitive thoughts and behaviors secret, failed to seek
treatment. This led to underestimates of the number of people with the
illness. However, a survey conducted in the early 1980s by the National
Institute of Mental Health (NIMH)--the Federal agency that supports research
nationwide on the brain, mental illnesses, and mental health--provided new
knowledge about the prevalence of OCD. The NIMH survey showed that OCD
affects more than 2 percent of the population, meaning that OCD is more common
than such severe mental illnesses as schizophrenia, bipolar disorder, or panic
disorder. OCD strikes people of all ethnic groups. Males and females are
equally affected. The social and economic costs of OCD were estimated to be
$8.4 billion in 1990 (DuPont et al, 1994).

Although OCD symptoms typically begin during the teenage years or early
adulthood, recent research shows that some children develop the illness at
earlier ages, even during the preschool years. Studies indicate that at least
one-third of cases of OCD in adults began in childhood. Suffering from OCD
during early stages of a child's development can cause severe problems for the
child. It is important that the child receive evaluation and treatment by a
knowledgeable clinician to prevent the child from missing important
opportunities because of this disorder.

Key Features of OCD

Obsessions

These are unwanted ideas or impulses that repeatedly well up in the mind of
the person with OCD. Persistent fears that harm may come to self or a loved
one, an unreasonable belief that one has a terrible illness, or an excessive
need to do things correctly or perfectly, are common. Again and again, the
individual experiences a disturbing thought, such as, "My hands may be
contaminated--I must wash them"; "I may have left the gas on"; or "I am going
to injure my child." These thoughts are intrusive, unpleasant, and produce a
high degree of anxiety. Often the obsessions are of a violent or a sexual
nature, or concern illness.

Compulsions

In response to their obsessions, most people with OCD resort to repetitive
behaviors called compulsions. The most common of these are washing and
checking. Other compulsive behaviors include counting (often while performing
another compulsive action such as hand washing), repeating, hoarding, and
endlessly rearranging objects in an effort to keep them in precise alignment
with each other. These behaviors generally are intended to ward off harm to
the person with OCD or others. Some people with OCD have regimented rituals
while others have rituals that are complex and changing. Performing rituals
may give the person with OCD some relief from anxiety, but it is only
temporary.

Insight

People with OCD usually have considerable insight into their own problems.
Most of the time, they know that their obsessive thoughts are senseless or
exaggerated, and that their compulsive behaviors are not really necessary.
However, this knowledge is not sufficient to enable them to stop obsessing or
the carrying out of rituals.

Resistance

Most people with OCD struggle to banish their unwanted, obsessive thoughts and
to prevent themselves from engaging in compulsive behaviors. Many are able to
keep their obsessive-compulsive symptoms under control during the hours when
they are at work or attending school. But over the months or years,
resistance may weaken, and when this happens, OCD may become so severe that
time-consuming rituals take over the sufferers' lives, making it impossible
for them to continue activities outside the home.

Shame and Secrecy

OCD sufferers often attempt to hide their disorder rather than seek help.
Often they are successful in concealing their obsessive-compulsive symptoms
from friends and coworkers. An unfortunate consequence of this secrecy is
that people with OCD usually do not receive professional help until years
after the onset of their disease. By that time, they may have learned to work
their lives--and family members' lives--around the rituals.

Long-lasting Symptoms

OCD tends to last for years, even decades. The symptoms may become less
severe from time to time, and there may be long intervals when the symptoms
are mild, but for most individuals with OCD, the symptoms are chronic.

What Causes OCD?

The old belief that OCD was the result of life experiences has given way
before the growing evidence that biological factors are a primary contributor
to the disorder. The fact that OCD patients respond well to specific
medications that affect the neurotransmitter serotonin suggests the disorder
has a neurobiological basis. For that reason, OCD is no longer attributed to
attitudes a patient learned in childhood--for example, an inordinate emphasis
on cleanliness, or a belief that certain thoughts are dangerous or
unacceptable. Instead, the search for causes now focuses on the interaction
of neurobiological factors and environmental influences.

OCD is sometimes accompanied by depression, eating disorders, substance abuse
disorder, a personality disorder, attention deficit disorder, or another of
the anxiety disorders. Co-existing disorders can make OCD more difficult both
to diagnose and to treat.

In an effort to identify specific biological factors that may be important in
the onset or persistence of OCD, NIMH-supported investigators have used a
device called the positron emission tomography (PET) scanner to study the
brains of patients with OCD. Several groups of investigators have obtained
findings from PET scans suggesting that OCD patients have patterns of brain
activity that differ from those of people without mental illness or with some
other mental illness. Brain-imaging studies of OCD
showing abnormal neurochemical activity in regions known to play a role in certain neurological
disorders suggest that these areas may be crucial in the origins of OCD.
There is also evidence that medications and cognitive/behavior therapy induce
changes in the brain coincident with clinical improvement.

Symptoms of OCD are seen in association with some other neurological
disorders. There is an increased rate of OCD in people with Tourette's
syndrome, an illness characterized by involuntary movements and vocalizations.
Investigators are currently studying the hypothesis that a genetic
relationship exists between OCD and the tic disorders. Another illness that
may be linked to OCD is trichotillomania (the repeated urge to pull out scalp
hair, eyelashes, or eyebrows). Genetic studies of OCD and other related
conditions may enable scientists to pinpoint the molecular basis of these
disorders.

Do I Have OCD?

A person with OCD has obsessive and compulsive behaviors that are extreme
enough to interfere with everyday life. People with OCD should not be
confused with a much larger group of individuals who are sometimes called
"compulsive" because they hold themselves to a high standard of performance
and are perfectionistic and very organized in their work and even in
recreational activities. This type of "compulsiveness" often serves a
valuable purpose, contributing to a person's self-esteem and success on the
job. In that respect, it differs from the life-wrecking obsessions and
rituals of the person with OCD.

Treatment of OCD; Progress Through Research

Clinical and animal research sponsored by NIMH and other scientific
organizations has provided information leading to both pharmacologic and
behavioral treatments that can benefit the person with OCD. A combination of
the two therapies is often an effective method of treatment for most patients.
Some individuals respond best to one therapy, some to another.

Pharmacotherapy

Clinical trials in recent years have shown that drugs that affect the
neurotransmitter serotonin can significantly decrease the symptoms of OCD.
Two serotonin reuptake inhibitors (SRIs), clomipramine (Anafranil) and
fluoxetine (Prozac), have been approved by the Food and Drug Administration
for the treatment of OCD. Other SRIs that have been studied in controlled
clinical trials include sertraline (Zoloft) and fluvoxamine (Luvox).
Paroxetine (Paxil) is also being used. All these SRIs have proved effective
in treatment of OCD. If a patient does not respond well to one SRI, another
SRI may give a better response. For patients who are only partially
responsive to these medications, research is being conducted on the use of an
SRI as the primary medication and one of a variety of medications as an
additional drug (an augmenter). Medications are of great help in controlling
the symptoms of OCD, but often, if the medication is discontinued, relapse
will follow. Most patients can benefit from a combination of medication and
behavioral therapy.

Behavior Therapy

Traditional psychotherapy, aimed at helping the patient develop insight into
his or her problem, is generally not helpful for OCD. However, a specific
behavior therapy approach called "exposure and response prevention" is
effective for many people with OCD. In this approach, the patient is
deliberately and voluntarily exposed to the feared object or idea, either
directly or by imagination, and then is discouraged or prevented from carrying
out the usual compulsive response. For example, a compulsive hand washer may
be urged to touch an object believed to be contaminated, and then may be
denied the opportunity to wash for several hours. When the treatment works
well, the patient gradually experiences less anxiety from the obsessive
thoughts and becomes able to do without the compulsive actions for extended
periods of time.

Studies of behavior therapy for OCD have found it to produce long-lasting
benefits. To achieve the best results, a combination of factors is necessary:
The therapist should be well trained in the specific method developed; the
patient must be highly motivated; and the patient's family must be
cooperative. In addition to visits to the therapist, the patient must be
faithful in fulfilling "homework assignments." For those patients who
complete the course of treatment, the improvements can be significant.

With a combination of pharmacotherapy and behavioral therapy, the majority of
OCD patients will be able to function well in both their work and social
lives. The ongoing search for causes, together with research on treatment,
promises to yield even more hope for people with OCD and their families.

How to Get Help for OCD

If you think that you have OCD, you should seek the help of a mental health
professional. Family physicians, clinics, and health maintenance
organizations usually can provide treatment or make referrals to mental health
centers and specialists. Also, the department of psychiatry at a major
medical center or the department of psychology at a university may have
specialists who are knowledgeable about the treatment of OCD and are able to
provide therapy or recommend another doctor in the area.

What the Family Can Do to Help

OCD affects not only the sufferer but the whole family. The family often has
a difficult time accepting the fact that the person with OCD cannot stop the
distressing behavior. Family members may show their anger and resentment,
resulting in an increase in the OCD behavior. Or, to keep the peace, they may
assist in the rituals or give constant reassurance.

Education about OCD is important for the family. Families can learn specific
ways to encourage the person with OCD by supporting the medication regime and
the behavior therapy. Self-help books are often a good source of information.
Some families seek the help of a family therapist who is trained in the field.
Also, in the past few years, many families have joined one of the educational
support groups that have been organized throughout the country.

If You Have Special Needs

Individuals with OCD are protected under the Americans with Disabilities Act
(ADA). Among organizations that offer information related to the ADA are the
ADA Information Line at the U.S. Department of Justice, (202) 514-0301, and
the Job Accommodation Network (JAN), part of the President's Committee on the
Employment of People with Disabilities in the U.S. Department of Labor. JAN
is located at West Virginia University, 809 Allen Hall, P.O. Box 6122,
Morgantown, WV 26506, telephone (800) 526-7234 (voice or TDD), (800) 526-4698
(in West Virginia).

The Pharmaceutical Manufacturers Association publishes a directory of indigent
programs for those who cannot afford medications. Physicians can request a
copy of the guide by calling (800) PMA-INFO.

Offers free or at minimal cost brochures for individuals with the disorder and
their families. In addition, videotapes and books are available. A bimonthly
newsletter goes to members who pay an annual membership fee of $30.00. Has
over 250 support groups nationwide.

March, J.S.; Mulle, K.; and Herbel, B. Behavioral Psychotherapy for Children
and Adolescents with Obsessive-Compulsive Disorder: An Open Trial of a New
Protocol-Driven Treatment Package. Journal of the American Academy of Child
and Adolescent Psychiatry 33: 3: 333-341, 1994.

Message From The National Institute Of Mental
Health

Research conducted and supported by the National Institute of Mental Health
(NIMH) brings hope to millions of people who suffer from mental illness and to
their families and friends. In many years of work with animals as well as
human subjects, researchers have advanced our understanding of the brain and
vastly expanded the capability of mental health professionals to diagnose,
treat, and prevent mental and brain disorders.

Now, in the 1990s, which the President and Congress have declared "The Decade
of the Brain," we stand at the threshold of a new era in brain and behavioral
sciences. Through research, we will learn even more about mental disorders
such as depression, manic-depressive illness, schizophrenia, panic disorder,
and obsessive-compulsive disorder. And we will be able to use this knowledge
to develop new therapies that can help more people overcome mental illness.

The National Institute of Mental Health is part of the National Institutes of
Health (NIH), the Federal Government's primary agency for biomedical and
behavioral research. NIH is a component of the U.S. Department of Health and
Human Services.

Acknowledgments

This brochure is a revision by Margaret Strock, staff member in the
Information Resources and Inquiries Branch, Office of Scientific Information
(OSI), National Institute of Mental Health (NIMH) of a publication originally
written by Mary Lynn Hendrix, OSI. Expert assistance was provided by
Henrietta Leonard, MD, and Jack Maser, PhD, NIMH staff members; Robert L.
DuPont, MD, The Institute for Behavior and Health; Wayne Goodman, MD,
University of Florida College of Medicine; and James Broatch, Obsessive
Compulsive Foundation, Inc.